In January of 1739, Alice O’Neal, the thirty-year-old wife of an Irish farmer, went into labor. O’Neal’s pregnancy had been unremarkable and there was no indication that her labor would be difficult, but after twelve days of intense labor, it was clear even to the most unskilled medical practitioner that both O’Neal and her child were in serious danger. In a desperate attempt to save the child, Mary Donally, O’Neal’s midwife, “performed the Caesarian Operation, by cutting with a Razor...the Abdomen and the Uterus.” The circumstances of this operation were far from ideal. Donally was forced to hold “the Lips of the Wound together with her Hand [while her assistant walked]...a Mile” to retrieve the silk and needles necessary to stitch the incision. The operation, however, was a resounding success. Within twenty-seven days of the surgery, O’Neal had recovered and was able to resume “the Manage[ment of] her Family Affairs.” In the years following this operation, O’Neal’s extraordinary story was widely circulated throughout the British medical community. As the story became better known, it underwent several revisions: the number of miles Donally’s assistant walked to retrieve a needle and silk thread increased dramatically (ultimately she was said to have walked nine miles while Donally held “the Lips of the Wound”), and Donally, in keeping with Irish stereotypes, was now said to have been drunk during the operation. Yet despite these changes, the essential story remained the same. A woman native to the United Kingdom had undergone and recovered from a caesarian operation under the most primitive of conditions.

For British men-midwives, most of whom had trained as surgeons, O’Neal’s case raised a new and exciting question. Could the caesarian section be performed successfully – that is could it enable women to safely deliver a healthy child? But, paralleling this question remained an age-old one: if doctors could not save both the mother and child through a caesarian section, which should be saved: the mother or the child? Beginning in the eighteenth century, these two questions became the focal point of a major debate throughout the British medical community. This debate, which continued well into the nineteenth century, demonstrates not only a shift in attitudes toward women and child but also the prevalence of anti-Catholic sentiments in Britain during this period. While the story of Mary Donally and her success in performing a caesarian section that saved both the mother and child seized the imagination of the British medical community, this story did not reflect the realities of eighteenth-century medical practice. Throughout this period the caesarian section was only rarely performed by either male or female midwives. This reluctance to perform a caesarian section stemmed, of course, from the high death rates associated with this procedure. Even its most avid supporters conceded that the death of the mother was a common occurrence during the procedure. John Hull, a man-midwife in Manchester, admitted, for example, that the mother was unlikely to survive a caesarian section. Of the seventeen cases that Hull cited in his book, A Defence of the Caesarian Section, fifteen had resulted in the death of the mother. Even the survival of the child was uncertain. Hull admitted that in at least one case, the child had also died.

Even idealized images of poverty showed the impact of poor nutrition. Early 19th c.

But these grim statistics were not, Hull insisted, sufficient reason to condemn this procedure. Arguing that the French routinely performed caesarian sections with great success, Hull and a variety of other British practitioners now began to insist that the “Caesarian Operation [wa]s not only justifiable but [also] a valuable and necessary resource” for British medical practitioners. In promoting this procedure, Hull and his colleagues argued that many pregnancies required extraordinary measures, and the evidence does seem to confirm this view. High levels of rickets as well as poor nutrition meant that many British working-class women had severe deformities and stunted growth. The existence of pelvic deformities and abnormally small women appears to have been such that even fervid opponents of the caesarian section were forced to concede that extraordinary measures – surgical procedures – were often necessary. When advocating extraordinary measures, however, many British medical practitioners did not call for the use of the caesarian section. Instead these practitioners called for the use of the craniotomy, a procedure that required the medical practitioner to kill the child in utero to save the mother. This procedure, many British practitioners insisted, was preferable to the caesarian section, which often killed the mother to save the child. Support for the craniotomy – and for saving the mother over the child – had a long history in Britain. Before the seventeenth century, the craniotomy had been used in most difficult labors. In fact, according to many medical practitioners, European midwives and surgeons had never used the caesarian section (stories that claimed that Julius Caesar and Edward VI of Britain had been delivered by a caesarian section were dismissed as apocryphal by the eighteenth century).

Brutal working conditions and poor nutrition stunted the growth of working-class women

But the successful and widely touted story of a Dutch woman who had successfully recovered from a caesarian section during the sixteenth century, combined with the introduction of the forceps in the seventeenth century, led many practitioners to rethink their approach to a difficult labor. By the eighteenth century, some practitioners were becoming convinced that medical technology had advanced to such a degree that a skilled practitioner could almost always save both the mother and child during a difficult pregnancy. Yet this optimism was, as Hull’s own work indicated, often misplaced. In opting for a caesarian section, many medical practitioners had simply traded the life of the child for the life of the mother. For many practitioners, this Hobson’s choice meant that the debate over the caesarian section remained grounded in the question of whether the mother’s life was more valuable than that of the child.

Dr. William Hunter, Ob/Gyn, 18th c.

Recognizing this to be an extraordinarily difficult question to answer, instructors of midwifery candidly encouraged their students to assess the economic and social worth of the mother and child. Obviously, this question varied according to the status of the family.

In an upper-class family, where an heir might be urgently needed, the life of the child was regarded as being more valuable than that of its mother (this was especially true in families where an estate was entailed (and entails were on the rise during this period). But these instances were, most practitioners admitted, extremely rare. When dealing with lower- and middle-class patients, William Hunter, an acclaimed midwifery instructor, recommended that his students “act as an Indian planter would.” Presented with the option of saving either the child or the mother, “what answer would the planter make?” According to Hunter, any planter would request the midwife to do “as you will with the Child [but] save the Mother [for] she is worth fifty pounds...[while] the Brat would not fetch...a Crown.” Hunter’s proclamation, which was made in 1768, was considered not only perfectly acceptable but also sound economic advice. This view, however, would be subject to change as Britain itself began to undergo the massive changes associated with the Industrial Revolution.

Join us here to discover how this debate continued to shape eighteenth-century medical practice.